תוצאת חיפוש

Willingness to Donate Organs: Attitude Survey among Israeli Jews

Peri Kedem-Friedrich, Rina Rachmani

Psychology Dept., Bar-Ilan University, Ramat Gan and Information and Education Unit, Israel Transplant Center

A public opinion survey of Israeli Jewish adults (September) showed a large potential willingness to donate organs after death, while only a third of the sample was opposed. Nevertheless, only a very minor proportion held donor's cards, and over half expressed opposition to holding a donor card. As to next-of-kin's organs, when the wishes of the relative were not known, a quarter of the sample opposed, a quarter agreed, and the remaining half hesitated to make a decision.

Willingness to donate was not correlated with gender, age or income, but was related to religiosity: the more religious, the less willing to donate. And the religious reason was the salient one given for hesitation about donating, although there were many who could give no reason for their hesitation. Family members, doctors and rabbis (in ascending order) influenced willingness to consent to next-of-kin donations.

Use of Restraints in a General Hospital

Bella Bar-Cohen, Orly Rotem-Picker, Zvi Stern

Nursing Services and Administration, Hadassah University Medical Center, Jerusalem

28 in-patient units were surveyed during a 5-day period to determine the extent of the use of physical restraints in hospitalized patients. Information was gathered on the characteristics of restrained patients and indications for use and removal of restraints, patterns and means of restraints, monitoring, and written notations. 31 different patients (6% of those surveyed) were restrained in 13 units during the 5 days of the survey, an average of 15 (3%) daily.

Characteristics of restrained patients were: age 70 and over requiring emergency hospitalization, reduced level of consciousness, limitation of mobility, incontinence, history of 2 or more chronic diseases, requiring multiple drugs, and use of multiple medical devices. Bilateral, soft hand restraints were most often used to prevent patients from removing tubes. Nurses initiated the decision to apply or remove restraints, which were usually removed as the patients' condition improved. Written policies were lacking regarding monitoring and follow-up of restrained patients. Clearly written policies and increased staff awareness of potential hazards may reduce the use of restraints and the length of time they are employed.

Normotensive Hydrocephalus Complicating Recurrent E. Coli Meningitis

Doron Zamir, Rasmi Magadle, Paltiel Weiner

Dept. of Medicine A, Hillel Yaffe Medical Center, Hadera

E. coli meningitis is a disease that occurs in predisposed patients, either as a result of trauma or in neonates after neurosurgery. Recurrent E. coli meningitis in an adult without any apparent predisposition is uncommon, and hydrocephalus complicating bacterial meningitis is even more rare. We report a unique case of a 67-year-old alcoholic man who had had 2 consecutive episodes of E. coli meningitis within 2 months. In both episodes there was a favorable response to ceftriaxone. However, normotensive hydrocephalus appeared a few weeks later, with mental and physical deterioration.

Serotonin Re-Uptake Inhibitors as Primary Therapy for Carotid Sinus Hypersensitivity

Amos Katz, Angel Kantor, Alexander Battler

Cardiology Dept., Soroka Medical Center and Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer Sheba

Carotid sinus syndrome is a well-recognized cause of unexplained syncope in older patients, and may lead to significant morbidity due to trauma from falls. Dual chamber pacing has been shown to be effective in relieving symptoms due to bradycardia, but not due to vasodepressor response. We report an 84-year-old man with recurrent syncope due to carotid sinus hypersensitivity. He was treated only with a serotonin re-uptake inhibitor and was symptom-free after 3 weeks of therapy. He has remained symptom-free for the past year.

Ultrasonographic Imaging of Superior Sagittal Thrombosis

Ilan Shelef, Avi Cohen, Yehiel Barki

Depts. of Radiology and Neurosurgery, Soroka Medical Center and Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer Sheba

Ultrasonographic findings of superior sagittal sinus thrombosis include dilated and hyperechoic sinus (direct imaging of the thrombus). No flow should be demonstrated by the various Doppler techniques. In the deeper sinuses, if the thrombus can not be visualized after a negative Doppler study, MR imaging is recommended. Recanalization and reflow can be demonstrated on follow-up study.

Methotrexate Treatment in Refractory Juvenile Rheumatoid Arthritis

R. Brik

Pediatrics B Dept., Rambam Medical Center, Haifa

The mean time from initiation of methotrexate (MTX) treatment of juvenile rheumatoid arthritis (JRA) to partial remission of clinical symptoms and total clinical remission was assessed. 9 girls and 8 boys, from 3 to 18 years of age (mean 11.4±5.4) with active JRA by American College of Rheumatology (ACR) criteria (5 systemic, 8 polyarticular and 4 pauciarticular disease onset), who failed to respond to adequate courses of non-steroidal anti-inflammatory drugs (NSAID), steroids or disease-modidrugs were studied.

Clinic visits were scheduled at monthly intervals for physical and laboratory assessment disease activity and drug safety. Partial response to MTX was defined a 25% reduction of the active joint count and/or articular severity score. Total clinical remission was defined as in adult rheumatoid arthritis. The duration of disease activity until enrollment ranged from 6 months to 14 years (4.5±3.7 yr); duration of therapy was 3 months to 3 years (14.6±9.3mo) and dosage ranged from 5 to 15 mg/m²/week. Prednisone in doses below 10 mg/day and NSAID were permitted.

14 of 17 patients (82%) had a 25% reduction in joint activity after 6 weeks to 4 months (9.2±3.2 weeks); 10 (59%) went into full clinical remission after 5 to 26 months (14.3±9 months); 3 relapsed after an initial response to treatment, and 4 (23%) did not respond to MTX. The non-responders were males who required higher doses of prednisone (p<0.0001).

MTX appears to be effective therapy for children with JRA. An initial response can be expected in most patients after 9 weeks of treatment, and full clinical remission occurs after a mean of 14 months.

Characteristics, Management and Prognosis of Acute Myocardial Infarction (Israel 1990-1996)

Israeli Survey Group On Acute Myocardial Infarction

From 1990 to 1996 we conducted consecutive 2-month surveys in all CCUs (n=26) in Israel. The aim was to compare the characteristics, management, and prognosis of patients with acute myocardial infarction (AMI) between the 4 surveys.

Patient characteristics were similar in all surveys. About 75% of patients were males and had a first MI. Mechanical and arrhythmic complications decreased slightly between 1990 and 1996. In contrast, frequency of treatment with thrombolysis, aspirin, beta-blockers and ACE-I, as well as coronary interventional procedures, increased tremendously.

In parallel, 30-day and 1-year mortality decreased significantly, from 16.5% and 22.5%, respectively, to 9.0% and 13.9%. After multiple adjustment for factors associated with mortality, the 30-day relative risk of death for patients hospitalized in 1992, 1994 and 1996 was 0.79 (95% CI 0.59-1.08), 0.75 (95% CI 0.56-1.01) and 0.54 (95% CI 0.39-9.74), respectively, as compared with 1990.

Although there is no direct proof that changes in management of AMI are related to the reduction in mortality seen during the course of the surveys, the association seems likely.

Thoracoscopic Surgery for Spon-Taneous Pneumothorax

H.R. Freund, O. Zamir, Y. Shifman, N. Beglaibter, Y. Haskel

Hadassah University Hospital, Mount Scopus and Hebrew University-Hadassah Medical School, Jerusalem

We report our initial experience with thoracoscopic surgery in the treatment of spontaneous pneumothorax in 14 patients, mean age 30.7 years. 7 were operated following 2 episodes of spontaneous pneumothorax, 6 after their first episode, and 1 after multiple episodes.

All underwent bleb resection, pleurodesis and tube thoracostomy; in 1 we converted to a limited thoracotomy (93% success rate). Only oral analgesia was required for postoperative pain control and patients were discharged 2.6 days after surgery, on average.

The apparent superiority of thoracoscopic over conventional, even limited, thoracotomy seems to justify such therapy even during the first episode.

Investigating Chest Pain: is there a Gender Bias?

Leonardo Reisin, Chaim Yosefy, Sharon Kleir, Emil Hay, Ronit Peled, Shimon Scharf

Cardiology and Emergency Depts. and Epidemiology Unit, Barzilai Medical Center, Ashkelon (Affiliated with Ben-Gurion University, Beer Sheba)

Ischemic heart disease (IHD) in women is characterized by a higher morbidity and mortality in the peri-infarction and coronary bypass peri-operative periods. These epidemiological data strengthen our impression that the health system unintentionally "ignores" the high proportion of females with IHD.

The process of investigating chest pain, diagnosing IHD, and the subsequent treatment and rehabilitation, seem to differ between the genders. Time elapsed from beginning of chest pain to diagnosis of IHD seems to be longer in women than in men. Personal, educational and social factors are contributory.

Although time elapsed between diagnosis and rehabilitation is usually similar in the genders, peri-operative morbidity and mortality are higher in women. It may be that the higher rates in women are caused by delay in diagnosis and treatment, which allows worsening of the disease in women before treatment. This delay can occur during the time needed for evaluation of chest pain, from the door of the physician to diagnosis and treatment.

In our retrospective study we determined the difference in referral of men and women with chest pain to the emergency department (ED) and the attitude of physicians in the ED and medical department to chest pain in men and in women, including final diagnosis on discharge. 615 patients over 18 years referred to the ED for chest pain during 3 randomly chosen, consecutive months were studied. We found that women constituted only 39.5% of the referred patients, but the proportion hospitalized was similar to that in men. Hospitalized women were older (57.7±18.4 versus 49.7±17.8 years in men), and had more risk factors (4 versus 2 in men). Proportions of specific diagnoses on discharge from hospital were equal in the genders.

To bridge the differences and to implement education in prevention, investigation and treatment of IHD in women, we established the "Female Heart" clinic. The objective of this clinic is to reduce differences in the first step, in the process of evaluating chest pain in women, by educating and encouraging them to present early to their physicians, and by changing physicians' attituin the investigation of chest pain in women. We plan to determine in a prospective study if these goals are.

Comparison between Every-Day and Every-3-Days Fluoxetine in Young, Moderately Depressed Out-Patients

A. Shiber, H. Reuveni, A. Elhayany, I.Z. Ben-Zion

Psychiatric Dept., Psychiatric Division, Soroka Medical Center and Ben-Gurion University of the Negev, Beer Sheba; and Medical Division for Drug Utilization, Kupat Holim Klalit (Sick Fund)

Fluoxetine is now a well-known and often-used specific serotonin reuptake inhibitor (SSRI) and antidepressant. It has a very long active half- life, from 2-16 days. Our hypothesis was that sufficient therapeutic effectiveness would be achieved by prescribing the drug less frequently than once a day.

To establish whether there is a difference between fluoxetine given daily or every 3 days, we assigned 25 outpatients with mild to moderate, acute major depressions (DSM-IV) to receive fluoxetine (20 mg), either each day or every 3 days. The study was open-labelled, using for assessment the HAM-D, GHQ-28 side-effect checklist and clinical judgment questionnaires. Follow-up lasted 6 months.

Results indicated no differences in the clinical outcomes, except for slightly fewer side-effects in the study group. Although the open label design limits drawing definitive conclusions, our preliminary results provide more information, and support our hypothesis that low-dosage fluoxetine is beneficial. However, more comprehensive, double-blind studies are necessary to confirm our preliminary results.

Risk of Transmission of Viral Disease by Needle Puncture in Health Care Workers

Yosef Mishal, Chaim Yosefy, Emil Hay, Dalia Catz, Elisia Ambon, Roza Schneider

Infectious Disease Unit, Emergency Dept. and Microbiology Lab, Barzilai Medical Center, Ashkelon (Affiliated with Ben-Gurion University of the Negev)

The accidental exposure of the health care workers (HCW) to blood and blood products constitutes a danger for transmission of blood-borne pathogens and the development of severe diseases. Most attention is focused on exposure to the viruses of hepatitis B, C and human immunodeficiency. The objectives of this prospective study were to determine the rate of exposure of our HCW to blood and blood products; to define the high risk groups; and to establish recommendations to prevent transmission or reduce the risk of exposure to these viruses.

During the year 1996, 103 injuries from needle-puncture or other sharp objects were reported to our infectious diseases control unit. Most of those injured were women. 58.4% of the events occurred in the vicinity of the patient. The source of exposure was known in 60% of the cases. 73.8% of those injured had already been immunized against hepatitis B. The departments in which most exposures occurred were the operating theater (12.5%), medical departments A (10.6%) and B (9.6%), and the emergency department (7.7%). Nurses were at highest risk, constituting 47% of those injured.

Our recommendations are that a continuous teaching program be established for the high risk groups; that HCW be urged to report every event of exposure; and to encourage HCW to undergo active immunization against hepatitis B.

The Surgeon and the Emperor: a Humanitarian on the Battlefield

M. Feinsod

Dept. of Neurosurgery, Rambam (Maimonides) Medical Center; B. Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa

The Baron Dominique-Jean Larrey, one of the greatest names in military surgery, participated as Chief Surgeon in all the Napoleonic campaigns. He developed the concept of early evacuation from the battlefield, and of immediate treatment of the wounded, even under fire. He implemented improved surgical techniques and improved wound care that were followed by surgeons all over Europe. His devotion to wounded soldiers crossed national boundaries and became a way of life. Here is an account of Larrey's involvement in the aftermath of the Battles of Lutzen and Bautzen (May-June 1813), when many soldiers were accused of self-mutilation and were about to be executed. He dared to oppose, singlehanded, the Emperor, the highest military authorities and their concurring physicians and surgeons, armed only by his undisputed honesty, professional authority and exceptional reputation won over years of devotion to wounded soldiers. Larrey saved the lives of many soldiers and set an example of unbent ethical integrity.

Empirical Treatment of Urinary Tract Infections in the Delivery Room

Peter Jakobi, Orly Goldstick, Renato Finkelstein, Joseph Itzkovitz-Eldor

Obstetrics and Gynecology Dept. and Infectious Disease Unit, Rambam Medical Center, Haifa

Urinary tract infection (UTI) is the most common bacterial infection during pregnancy. In prenatal and delivery wards treatment is usually started at once in pregnant women with symptoms suggesting UTI, but there is no uniformity as to treatment. We surveyed such treatment in the delivery rooms throughout Israel, and whether the treatment differed in simple cystitis as opposed to pyelonephritis. Results of positive urine cultures from symptomatic parturients admitted here during 1995-1996 were examined.

There were 17 different empiric treatment protocols in 28 delivery rooms, whose daily cost ranged from 1-119 NIS. We present the antimicrobial sensitivity of 156 bacteria isolated from the urinary cultures from pregnant women in our prenatal ward. Based upon urinary flora, sensitivity and daily cost, we suggest a protocol for empiric treatment. We recommend first and second generation cephalosporins for treatment of simple lower (UTIs), while gentamicin is suggested for treatment of clinical pyelonephritis during pregnancy. There is no medical nor economic justification for the multiplicity of empiric treatment protocols currently used. Considering our results, our protocol is cost-effective for the empiric treatment of UTI in hospitalized parturients and in the community as well.

Nasopharyngeal Colonization with Streptococcus Pneumoniae in Pediatric Respiratory Infections

Isaac Srugo, Irena Chystiakov, Ella Cohen, Yoram Tal, Michael Jaffe

Clinical Microbiology and Pediatric Depts., Bnai Zion Medical Center and Technion Faculty of Medicine, Haifa

During the winter of 1995, nasopharyngeal colonization of Streptococcus pneumoniae was evaluated in 204 children with respiratory infection and 107 normal control children. There was no difference in gender or mean age between the groups, and no difference in carrier rate between sick (24.5%) and normal (22%) children (p=0.6). Carrier rates were 19%, 32%, 31% and 17% at 6, 12, 24 and 48 months, respectively. Penicillin-resistant pneumococci (PRP) were found in 42% of sick and 16.6% of normal children, (p<0.05). Resistance to more than 2 antibiotics was found in 28% of sick and in 12.5% of normal children. PRP were found in 67% and 34% of sick children with and without prior antibiotic treatment (p<0.05). We conclude that there is no difference in the carrier rate of Streptococcus pneumoniae between sick and normal children. However, the high prevalence of PRP in children with respiratory infections is probably due to prior antibiotic treatment.

The Diagnosis and Treatment of Fournier's Gangrene

M. Cohen, E. Tamir, S. Abu-Abid, Y. Galili, M. Giladi, S. Avital, R. Shafir, Y. Klausner

Surgery and Infectious Disease Depts. and Division of Surgery, Tel Aviv-Sourasky Medical Center, and Sackler Faculty of Medicine, Tel Aviv University

We treated 2 women and 8 men suffering from Fournier's gangrene during 1990-96. 2 had diabetes, 1 suffered from ulcerative colitis and 1 was an alcoholic. In 8 of them the infection was triggered by a mixture of aerobic and anaerobic bacteria. Treatment consisted of repeated wide debridement and early colostomy. This aggressive approach resulted in relief of the septic signs within 24 hours and permitted early skin grafting of the wounds. 2 patients died due to sepsis that caused multiple organ failure. The 8 who survived were hospitalized for an average of 35 days. On follow-up examination 1-5 years later all patients had undergone closure of the colostomy and were completely rehabilitated.

Fournier's gangrene is not rare in the geriatric population. We believe that early diagnosis and aggressive wide debridement, combined with early colostomy, are the keys to successful treatment.